<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:19:44 PM


Document Has Been Signed on 10/05/2022 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:RODRIGUEZ, BRANDEEFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 55DATE:
10/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH: Interim Administrator Camille BrownTIME COMPLETED:
03:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Camille Brown, Interim Executive Director(IED). The purpose of this case management inspection is to follow up on three self reported incident reports submitted to Community Care Licensing (CCL) 9/9/2022 and two on 9/22/2022.

CCL received a self reported incident report reporting on 8/30/2022 at 9:00 PM of R1 having episodes of aggression and agitation towards staff. R1 was sent out to the hospital and admitted. During today's inspection LPA was informed R1 was brought back to facility after six days without catheter and follow up with PCP. R1 is back at baseline without any other incidences.

LPA obtained additional information regarding an incident that occurred on 9/20/2022 at 8:30 AM involving R2. R2 was noted with facial grimacing, complaining of back pain, and unable to ambulate. R2 was seen at the ER and admitted for sacral fracture, all parties notified. IED informed LPA, R2 was sent to skilled nursing facility (SNF) for rehab and is still there. Follow up meeting this week with facility, PCP, and SNF indicate R2 would be returning in approximately one week with PT at facility as R2 is having difficulty with dementia and following PT at SNF. R2 is recovering well.

LPA followed up on an incident that occurred on 9/22/2022 at 9:00 PM where R3 had showed aggressive behavior towards staff, staff was unsuccessful at redirecting emergency services was called. All appropriate parties were contacted. Facility is working with PCP and responsible party.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1